Abstract
Siri Suh’s Dying to Count is a powerful exploration of the women caught by reproductive governance and surveillance in Senegal and the complications that make statistical record keeping a threat to public health. The book is the result of Suh’s fieldwork in three hospitals, which included shadowing post-abortion care (PAC) workers, in-depth interviews with health care providers, and the analysis of PAC records. While Suh’s work examines PAC in Senegal, her findings speak to transnational patterns in gendered oppression and the global interventions that reify these oppressions. While Suh interviews PAC workers who refer to the global PAC model as “transformative,” she finds ample evidence of obstetric violence and persistent inequalities.
As a scholar of reproductive health in the United States, I was eager to review this book and learn more about reproductive health outside the United States. Unfortunately, what becomes abundantly clear is that the United States cannot be ignored. Suh illustrates how policies, ideologies, and crucially funding from the United States shape the reproductive lives of millions outside of the United States. Abortion policy is precarious at best in the United States and the failure to secure abortion access domestically imperils the lives and well-being of those in developing nations. USAID (United States Agency for International Development) fluctuates based on presidential administrations and their stances on abortion. Policies are enacted based on conservative values rather than public health research or past policy outcomes. Ironically, when U.S. administrations restrict funding and enact gag rules to sanction abortions, abortions increase globally.
This work paints a stark picture of vulnerable women abandoned by design by international policies. Suh’s work demonstrates how it is the most vulnerable populations who bear the brunt of national projects. Global systems of reproductive governance harm all people, but it is people capable of pregnancy who face the harshest sanctions. Predominantly white countries (especially the United States) continue supporting policies that increase maternal mortality and decrease national birth rates in predominantly Black and Brown countries. Which leaves the reader wondering: what exactly are these policies trying to accomplish?
This work does not center the United States but explores how harm is enacted across a myriad of levels and organizations. Harms are not only perpetuated from the top down but through mismatches between PAC as intended and as practiced and interference from anti-abortion local actors. Material limitations such as a lack of resources and physical space for private consultations can endanger those seeking emergency care. Social and political limitations at the local and interpersonal level such as local authorities who block PAC workers from accessing the resources they need also contribute. People in need of PAC must navigate multiple layers of legal, medical, and social risks. In many cases, they may decide to take their chances without care. Each set of decisions introduces more opportunities for miscounting the scale and scope of reproductive health needs in Senegal.
Suh provides a fascinating case to explore the neoliberal and inherently colonial practices needed to record and track populations. Her case highlights the inadequacies of these practices to capture the material conditions in which people make decisions about their reproductive lives. Inaccuracies in recording abortions and PAC related care misrepresent the scale and scope of people seeking abortions and the number of unsafe abortions being performed. These inaccurate statistics support and promote PAC globally as an effective program to address maternal and infant outcomes instead of calling attention to interventions that would target the root causes that necessitate PAC. The focus on PAC undermines the lack of accessible, affordable, safe abortions in developing countries.
Social statistics and public health courses would benefit significantly from a close reading of this book. Suh’s work asks the reader to reflect deeply on the implications of missing and inaccurate data. This work contributes to conversations around how we handle incomplete and missing data beyond using statistical work arounds and complex imputations. Suh asks us to interrogate where our data come from and what data truly are. Are they a count with missing information or are they capturing something else entirely?
Suh’s theoretical contribution makes this book an excellent choice for scholars of reproductive health, transnational/global sociology, and public policy. Violence and care are intertwined with care leading to structural violence in a vicious cycle at the expense of vulnerable women. When care workers do not act as state surveillance by recording legal abortions, their patients are protected individually, but missing and inaccurate data lead to structural harms on a grander scale. The failures of developed nations, particularly the United States, to support and fund evidence-based practices to protect maternal and infant health outcomes compounds raced, and economic inequalities. Suh’s work is an exceptional call to view reproductive health in its full context politically, materially, and globally. While her case is within the nation of Senegal, Dying to Count offers a powerful argument to think beyond borders regarding reproductive health policy.
This book touches on gendered policies, state surveillance, incarceration, and systemic global inequalities. It would not be out of place in a medical sociology, race and inequalities, or law and society course. Suh expertly demonstrates how reproductive health and the state are inextricably intertwined and the ripple effects of U.S. policies and resource allocation. I would particularly recommend this book for courses traditionally focused on policy and/or health in the United States as a way to encourage students to think more broadly about policy impacts and policy evaluation.